55/M Pyrexia under evaluation with cervical laminectomy 2 months back

 Chief complaints:

  Patient came with cheif complaints of burning type of sensation of whole body since 1 week.

Fever since 1 day

HOPI: 

Patient was apparently asymptomatic 2 months back after which he had an RTA during which he had cervical cord stenosis and was operated with cervical cord laminectomy i/v/o weakness of both upper and lower limbs. After which patient was on physiotherapy and power improved gradually.Now patient had h/o burning sensation and numbness of whole body( paresthesia).

He also have complaints of fever since today afternoon associated with chills , relieved on medication.

H/o of  burning micturition since 4-5 days 

No H/o decreased sensations

No h/o bowel and bladder incontinence.

No h/o seizure activity

No H/O cold, cough, sore throat

No H/o nausea , vomiting, pain abdomen

No H/o loose stools

PAST HISTORY:

Not a k/c/o dmII, htn, thyroid disorders,asthma,epilepsy

GENERAL EXAMINATION:

Patient is conscious, coherent

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema,

Temp: 101.5 degree F

Pr: 98bpm

Rr: 20cpm

Bp:130/70mm Hg

Grbs:151mg/dl

SYSTEMIC EXAMINATION

Cvs:S1 S2 heard , No murmurs 

Rs: BAE +, NVBS

P/A:  NT

CNS:

Tone  UL       LL

R          N         N 

L           N         N

Power : UL        LL

R           2/5       4/5

L           3/5         4/5 

Reflexes -   B    T     S     K      A   P 

RT-             +3   +3   2+   3+     3+   F

LT-              +3   +3   2+  3+     3+   F

INVESTIGATIONS:

4/6/23

5/6/2023

6/6/23

DIAGNOSIS:

  Pyrexia under evaluation with cervical laminectomy 2 months back

TREATMENT:

1. Inj Neomol 1 GM iv/sos ( if temp > 101 F)

2. Inj Monocef 1 GM iv/ bd

3. Inj optineuron  1 amp in 500ml NS /OD

4. Tab dolo 650mg Po/ Sos

5.tab pregabalin 75mg po/Hs